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Community and hospital pharmacy collaborate to reduce readmissions

July 1, 2013

Medicare says it spends more than $17 billion a year on hospital readmissions that could have been prevented if Medicare patients had gotten the right care. A leading problem is that patients don't take their medication properly after leaving the hospital.

Western Maryland Health System (WMHS) in Cumberland, Md., is on the cutting edge of the effort to reduce unnecessary hospital readmissions that result from patients failing to take medications properly after leaving the hospital.

The hospital is a leader in "bedside pharmacy" - a best practice technique that focuses on educating patients on discharge day about the importance medication adherence. The innovative practice also makes sure patients aren't thwarted by price, availability or complexity when trying to adhere to their post-hospital medication regimen.

"Bedside pharmacy" is a fascinating new best practice idea because it solves two problems at once - it improves patient health and reduces the potential of penalties under the Affordable Care Act for avoidable readmissions.

How can hospitals fix the financial risk and improve patient outcomes? Hospitals are trying new ways to better educate patients and caregivers about taking medications properly after discharge. Western Maryland Health System (WMHS) is one of true innovators on the issue, especially in its efforts to involve community pharmacists. The result is an informative case study about how the continuum of care improves when the hospital and community pharmacy coordinate the transition from hospital to home.

Take a look at one success story. WMHS had been partnering with a local retail pharmacy, PharmaCare to deliver pharmacy services to its nursing home and infusion and chemotherapy support services. In 2011, the hospital expanded its relationship with PharmaCare to include a new patient discharge process. The new program included in-depth medication plan reviews with patients, plus specific directions for post-discharge follow-up.

The primary goal? To reduce hospital readmissions by improving patients' understanding of their medications. Changing the hospital-retail pharmacy partnership created a win-win situation for everyone -- the hospital, the pharmacy and, more importantly, for patients. A great side effect - this practice reduces the burden on Medicare too due to lower re-admission rates.

Here's how it was done, and the key takeaways from this successful program:

Get a complete list of medications, up front

WMHS changed its admission process to ask each patient whether they had a primary pharmacy. Medical and pharmacy coverage don't always coincide, so problems with medication reconciliation are common. This first step provided a way to bill insurance, if needed, and ensured that both the hospital and the retail pharmacy could obtain a full list of patient medications. This helped PharmaCare prepare some prescriptions ahead of time, saving time and reducing the risk of missed medications due to an incomplete list from patients or caregivers.

Proximity is key

PharmaCare operates a retail pharmacy within one of WMHS's newest hospitals. The on-site retail pharmacy was originally created to help the health system with employee prescriptions, but it also provided a perfect location for PharmaCare to engage with the hospital's discharged patients. When the program launched, nurses would bring patient demographic information and prescriptions to PharmaCare's on-site pharmacy. PharmaCare pharmacists would fill the prescriptions, and the nurses would take the drugs back to the patient with instructions. However, the team soon adjusted the model in a crucial way: Connecting patients directly with the pharmacist improved medication compliance.

Connecting patients directly with pharmacists

To support the idea of direct pharmacy-patient relationship, PharmaCare added a second pharmacist to its staff. In the new arrangement, one pharmacist took primary responsibility for the pharmacy itself. The other started in the pharmacy, then took medicines to patients "on the floor" and talked to patients prior to discharge. The second pharmacist worked during the hospital's busy discharge hours, and the hospital compensated PharmaCare for that time, on an hourly basis. This arrangement created a new revenue stream for PharmaCare, a reward for providing the hospital with a valuable new service.

The pharmacist visited patients in their rooms - thus, the new term "bedside pharmacy." The pharmacist checked each patient's chart to review key information, such as the patient's admitting diagnosis and any other diagnoses, as well as admitting medications and home medications. The pharmacist reviewed this information to ensure that no home medications were duplicated or missed. The pharmacist counseled each patient and walked him or her through the full medication regimen. Each medication was shown directly to the patient --- an opportunity for the pharmacist to explain the drug's purpose, schedule, directions and potential side effects. During this process, some patients would recognize medications that they were already on but hadn't listed on paperwork. This process increased the likelihood that the patient, along with family or caregivers in the room, understood the need for each medication, how to realistically maintain the treatment regimen and what side effects to expect.

Keeping the patient connected to the health care system

Patients received follow-up calls from the hospital after discharge. They were given the option to receive their discharge medications from PharmaCare or from another pharmacy. Patients who chose PharmaCare received a pharmacist consultation in their room. Discharge medications were billed to them in 20 to 30 days, rather than requiring payment up front. Reducing the financial burden, and giving the patient time proved to increase medication compliance.

Impressive results

The program's primary goal was to decrease the hospital's readmission rate, a key measure for hospital reimbursement under the Affordable Care Act. The program succeeded. Readmissions dropped 28 percent in the first year of the program. More progress is expected as the program's scope expands.

Just as noteworthy, patients have provided positive feedback in the hospital's discharge surveys. Patients' positive ratings on medication education and discharge instructions improved from about 65 percent to more than 90 percent.

An additional benefit was that patients learned how much prescriptions would cost outside the hospital. If necessary, the hospital could shoulder some of the cost of extremely expensive drugs to promote adherence. The hospital also could tap into manufacturer-sponsored patient assistance programs to help ensure that patients were financially capable of filling those prescriptions after their initial discharge. These efforts reduced readmissions by minimizing cases in which patients don't fill any prescriptions or only filled the cheapest ones.

Good patient care doesn't have to cost the hospital more money. PharmaCare's business has improved, too. The pharmacy estimates that20 to 30 percent of the hospital's outpatients continue to fill their medications at PharmaCare. Some patients' family members have moved their business, too. This leads to additional revenue for the retail pharmacy and, more importantly, ensures patients have continuity of care after they leave the hospital.

Better care. Fewer readmissions. Lower costs. It's an example of how collaboration between community pharmacists and hospitals can achieve the goal of cost-effective healthcare.